Anonymous Harassment Reporting Form

You are not required to provide your name unless you wish to. This form is strictly confidential and may be submitted anonymously. This form can be used for retaliation following an initial reporting of harassment.

Note this page is hidden from the public and the data sent to the owner of the clinic via email.

2. Who was involved? Person/s involved

Were there witnesses?

Yes

No

Not sure

3 . What happened? Describe the incident (what was said/done, when, where, frequency):

4. Impact on you/others

6. Desired action

7. Additional information

Please enter anything else not covered here.